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Self Referral Form

Our 'At Home Support' service aims to provide young people with disabilities and their families the care they require at home during these unknown times. 

We live in unprecedented times, so Menphys are adapting our services to meet the needs of disabled children, young people & their families across Leicester, Leicestershire & Rutland. In order to reach those most in need we need to know who they are.

The Family Self-Referral form is to register for the Menphys In the Home Support Service and future Menphys Services. 


The Menphys In the Home Support Service aims to help as many families as possible across Leicester, Leicestershire and Rutland during the Coronavirus pandemic by delivering themed Menphys Care Packages directly to the homes.  The themed Menphys Care Packages may include Amazon film rental vouchers, toy bundles, activity packs or hot meals.  Unfortunately, due to accessibility, locality and resource limitations, there is no guarantee on a timeframe of individual offers, frequency of offers to your household and the content of our Menphys Care Packages.


In order to successfully self-refer ALL details must be completed and submitted.  Please allow up to 5 working days for an acknowledgement email confirming your Family Self-Referral has been received.


Upon availability and suitability, you will be contacted via the contact information provided to offer you a themed Menphys Care Package to be delivered to your door (following government guidelines on social distancing) for your family to benefit from.

Contact Us

Thanks for submitting!

By contacting and providing your family information, you and the named family members are consenting to Menphys using and securely storing your information for the Menphys In the Home Support Service and all Menphys communications for the duration.  The consent to use and securely store your information includes data, photos and videos across all Menphys communications online and offline for the duration.  To opt out at any time, please email directly.